Personally Pretentious Prattle.

January 28, 2014

We've got lots of people speaking out about mental illness, and preaching the message that it's okay to talk about, to get over the stigma surrounding it. It's a real problem that causes too many people to suffer needlessly. Luckily, attitudes seem to be changing, at least among younger people.

The Governor General and his wife gave an interview yesterday encouraging people to talk about it and ask for help. But what happens then?

The string of military suicides and the issues they have exposed has brought questions about the mental health system back into the public awareness, exposing many of the shortcomings. Let's talk about that.

In fact, let's talk about what many peoples' experience is dealing with the mental health system.

For some people, things work out okay. I've long dealt with dysthymia and the occasional bout of MDD. Given awareness of symptoms, family history, etc. it was something that has been on my radar screen for a long time. Exercise helped keep things in check for a long time. When an hour a day, seven days a week wasn't enough to keep things in check, my family doctor (who had been in on the loop) and I agreed it was time to add an antidepressant. That was over ten years ago, and to this day an exercise routine and a combination of antidepressants is still more-or-less good enough to keep me functional.

Of course, this scenario presupposes people are aware of their symptoms, willing to talk about them, have a family doctor (hardly a sure thing), have a good family doctor (also not a sure thing), and have one that is both knowledgeable and comfortable dealing with mental health issues.

Frighteningly, there are many doctors who don't want to deal with mental health in their practice, and it's far from unusual for them to further stigmatize their patients. You really don't want to hear "just snap out of it" or "go to church more" from a physician when coming in with serious mental health issues, but that's the reality many people face. Not exactly the gateway to the system you want to see, especially if you don't have the knowledge to understand how full of crap that is.

But, for most people if they can get in and talk to their family doctor, and their family doctor is receptive, they'll get put on an antidepressant. Usually without enough counselling about how it works, side effects, what to watch for, etc. And sure, there may be lots of other things going on, but in your average hurried medical appointment these days, what else are they going to have time to do? With the patient load they have to carry, there just isn't enough time for most family doctors to do much more.

If you get referred to a psychiatrist, good luck on that front. Waiting lists are very long, because there aren't nearly enough psychiatrists available either. When you do get in, you have no idea how long they'll spend with you, if they'll actually listen, or if they'll just adjust your psychotropics and send you on your way.

Why is that? Because every psychiatric practice is different, every psychiatrist has different areas of interest, and different treatments they offer. Most people don't know that. You're counting on your family doctor referring you to an appropriate psychiatrist for your problem, which isn't always the case. How long you wait, how long you're seen, if you're seen only once or for ongoing treatment, and what the psychiatrist looks at also depends heavily on how the family doctor writes up the referral. Good luck if you have a family doctor who just doesn't want to deal with any mental health issue. Most people don't know that either.

If you've dealing with mental health issues with your underage children, all the above applies, except it's ten times worse, because there's an even greater shortage of child psychiatrists, and most of them are even more sub-specialized.

Think psychotherapy might be the answer? Not an insurmountable problem if you have money or private insurance that will cover it. While in Canada psychotherapy provided by physicians is fully covered under provincial health plans, far fewer physicians (both family docs and psychiatrists) offer it than is required, again because of large patient loads, and the fact that it takes a lot more time than sending someone on their way with an antidepressant. There are lots of psychologists (many of them very qualified, but then again, not always), but that takes money.

Need more intensive treatment? Most inpatient beds are for acute care (i.e. actively suicidal) and patients are discharged long before they are fully well. Yes, there are specialized inpatient and outpatient programs available for less acute, more chronic psychiatric care, but like with the rest of the medical system in Canada, they are harder to access than emergency care.

For "serious" mental illnesses (e.g. schizophrenia), there are a good number of community-based programs around to help keep people out of hospital, but again, the amount of resources dedicated to them pales in comparison with the demand.

People like to talk about the mental health "system", but it should be pretty obvious that there isn't actually a system. Instead, we have a disjointed set of independent care providers who have different competencies, attitudes and capacities, each connected to some effectively random set of other care providers.

Falling through the cracks isn't a possibility, it's almost inevitable. And it's left up to the patient or their supports to both recognize it and navigate through.

Is it really this bad?

Pauline's private psychiatric practice is a bit of a "boutique" practice, in that she tends to see patients more often and for longer than many other psychiatrists would. She offers a wide range of treatments including psychotherapy. She'll see most patients for a two hour initial consultation, and it's not uncommon for even one-time consultations to come back to finish things up if that wasn't enough time or if more investigations are needed.

After years of what sometimes feels like "assembly line" psychiatry, she enjoys being able to treat and care for people the way she wants to. But because that takes more time, she can only manage a relatively small number of patients. They don't have to pay or anything to get access, but it does mean she has an extremely long waiting list.

I help her out in her front office a lot, and so get to know a lot of her patients too. So many times I've heard things like "finally I feel listened to" or "I'm so lucky to have found her" or "at last I feel like I'm being treated like a person who matters". And these are comments from people who have seen many care providers in the past.

While I could just say "wow, she's good" (which I think she is), I think it's more striking how hard it has been for so many of her patients, many of whom have out of necessity become extremely knowledgeable about the mental health system, and who have seen a lot of care providers, to find the right care for them.

For way too many people, the right care just isn't available due to availability (no provider or providers at capacity), affordability, access (unable to get referral), or the systemic or knowledge roadblocks that can be set up at every step in the process.

In some places, she couldn't even offer that kind of care... well, she could, but she'd be losing a fortune. In BC for example, psychiatrists are paid a fixed rate for a consultation (no matter how long it takes, which means if you spend the extra time to do a thorough job, the bulk of it is unpaid work). They also have to justify seeing patients more frequently (even if they're doing unwell for a period of time), and need them to basically be re-referred to care for them longer than six months. There are lots of other things she does now that would also be uncompensated there.

That's effectively a policy decision in BC due to the extreme shortage of psychiatrists vs. the demand. They've tried to put rules into the system to ensure as many people get access as possible, at the possible expense of the best care for each and every one who does get seen. It's an arguable, but entirely reasonable choice. Here in Alberta, it's far more laissez faire as far as policy goes.

At her office, I field a lot of calls from people looking to get help. I do my best to point them in the right direction and help them understand and navigate the system, and often they're grateful someone is willing to help even that much. But I know the odds are against them, and even the little bit of advice I can offer is only because with her seeing relatively few patients, the front office side is far less busy than in a typical overworked doctor's office.

We've been talking for a long time about getting past the stigma, and that's a talk that still needs to continue happening.

But we also need to do a lot more talking about what happens when people do try to seek help, about the kind of mental health care we provide, about the quality of care, the type of investments we're willing to make in the system, and ultimately about the kind of society we want to have.

The new regulations may sound like an appeal to big business (while shutting down small business), but they're much more about shutting down the whole thing. Under the old regime, Health Canada approved individual users who could then order/produce as needed. Under the new regime, Health Canada's only involvement is to approve (all) producers. It's up to physicians to effectively 'prescribe' certain amounts like they would with other medications.

Unfortunately, with no rigorous evidence-based studies on effectiveness of particular strengths and quantities for particular usages, and all liability risks as to the appropriateness of the decision to 'prescribe' and subsequent consequences placed solely on the physicians, pretty much every organization in the country that advocates for, regulates, or indemnifies physicians is warning them to stay as far away from this as they can.

Net result? Under the new regime it will be pretty much impossible for anyone to actually get medical marijuana because they won't be able to find a physician willing to 'prescribe'. Business will get no benefit because of no demand. Harper government can crow about their business friendly stance, show how the free market indicates there is no demand for this, and eventually kill the program altogether.

Death (or unnecessary suffering) by 1000 cuts (much more than 1000 independent producers). Hurray for ideology.

August 13, 2012

Probably going to be a winner for me. Pauline has an iPad (3) which I find a bit too large to lug around. I actually bought a Playbook a few weeks back, and while the size was right, the software on it was just so painful to use I returned it a week later.

It was actually more convenient to just use my previous generation iPod Touch on a recent short trip (the alternatives being the Playbook or dragging along a long-in-the-tooth laptop). Worked out better than I thought it was going to.

No longer trips planned for a while, but I think a 7" iPad (and a Bluetooth keyboard to pull out for any longer email sessions) might be just the ticket for future travel.

July 05, 2012

There's been a lot of recent political and media discussion regarding Primary Care Networks in Alberta. I think a lot of it has been overly simplified, mischaracterized, and misses some of the real issues. I want to try to clarify some of that if I can.

Caveat. I'm not in the healthcare industry. My (excellent) family doc is part of a PCN though I've never used any of its services. I know a number of other people who work or have worked at various other PCN's, and observed enough of the workings of at least one PCN (and many other healthcare organizations, in Alberta and Ontario), and know a lot of doctors and how they run their businesses. I think I have a pretty good sense of things.

The PCN Motivation. For family care physicians, the benefit of the PCN's are that a group of clinics can get together and acquire some resources to provide services to their patients that any individual clinic wouldn't be able to afford/justify. For example, a single clinic may not have enough patients to put on a regular "stop smoking" group, but a group of clinics can.

Myth: Doctor's run PCN's. A widespread myth is that family physicians run the PCN's. Technically yes, in the same sense that board chairs run large corporations. The reality is doctors are already swamped with work with their own patients, generate hate administration, and frankly, aren't too good at it. So the doctors who (along with AHS) "own" the PCN's hire full-time administrators who actually run things and make most policy and implementation decisions.

Primary Clinics are More than Just Doctor's Offices. Sure, the idea is that the PCN's are really a "network" of clinics, but the aforementioned administrative responsibilities mean that each PCN has what amounts to a fully staffed "head office". A good chunk of the money that goes to funding PCN's covers these offices, and the administrative staff that works there. A full third of PCN paid staff can be just admin support people. And this doesn't include the admin support people (receptionists etc.) that work at each clinic in the PCN - they're funded as overhead like in any other doctor's office.

Now, that leaves a lot of other people that PCN's pay, including clinical staff. For example, most PCN's pay a certain number of mental health therapists, many who will spend part of their time at individual PCN clinics working with patients, and some time in the PCN "head office" e.g. doing groups, participating in team meetings, etc.

Nobody knows if PCN's are successful. The recent Auditor General report makes it clear that since we're not measuring anything, we have no idea what PCN's are actually accomplishing. That doesn't mean they aren't doing anything - they are. It's just hard to say what. Especially when it comes to clinical outcomes.

I think if there was a review, they'd probably find that there's too much centralized administration for the amount of services that they provide, there is no standard in what services are provided, and there's not enough information sharing and learning between each PCN and other organizations

Funding Model and Lack of Accountability Promote Bureaucracy. PCN's are paid per patient that are 'rostered' (e.g. officially under the care of a family physician who is a member of the PCN). With no accountability on how money is spent, there is no incentive to provide any particular programs or services, but there is an incentive to increase the number of rostered patients. Because of this, and because as mentioned earlier the PCN's are de facto run by full-time hired administrators, the temptation is to increase the size of administration, creating a self-sustaining bureaucracy. I believe many people in the know would agree this has been the result.

This is in marked contrast to the funding model proposed for the new Family Care Clinics, which would be largely funded based on the medical services provided, rather than number of patients. This produces incentives to maximize the amount of services and reduce the amount of administration (treating it like the overhead it is, which corresponds to how administration is treated in doctor's offices). Note the contrast with PCN's.

PCN's shouldn't compete with other health organizations. It's also the case that bureaucracy run amok becomes self serving, and needlessly competes with other areas of the healthcare system. Example, one of the PCN's has a good number of mental health coordinators, and access to one psychiatrist for med consults a half day every second week. When PCN administrators try to lean on family physicians to refer people who need mental health care through the PCN mental health coordinators, and actively discourage them from referring directly to a psychiatrist (outside the network), even when the outside psychiatrist can provide better and more appropriate care for the patient, that's just dysfunctional. And when the mental health coordinators are instructed not to get advice from outside specialists, well, that goes well beyond the realm of common sense.

Myth: Doctor's favour PCN's because they can be gatekeepers. The reality is that family doctors want access to resources for their patients. Having access to a mental health therapist, pharmacist or dietician through the PCN's is great for them and their patients. Frankly, I don't know how many would really care that much if their patients could access a dietician without them explicitly being referred by the doctor, as might be the case in the new Family Care Clinics. As long as their patient could access those resources, most would be mostly happy.

Government vs. the AMA. I think the real reason that the AMA is upset about the whole FCC idea is that there is a longstanding lack of trust, and a long history of poorly thought out government initiatives that have been imposed on them without any real thought of consultation (starting with Klein's cuts, through AHS, etc.). The FCC model may well be a decent one, but coming up with it in the panic of an election campaign without adequate consultation was not the best way to approach it. And ramming it through afterwards "as is" reaks of political expediency.

So I think the "docs have control" in PCN's and might have to give it up a bit in FCC's is way overblown. It's mostly a broader issue of trust.

As an aside, given what we know about the lack of accountability with the current PCN's, I'm not surprised the government removed any reference to them in their current contract negotiations. Again, not great in terms of the perception that things are being imposed rather than negotiated, but I sure wouldn't want that albatross around my neck if I were the health minister.

What everyone really wants. I think everyone (patients, government, family docs) wants funded, stable, predictable and hassle-free access to things like being able to see a family doctor in a timely manner, access a specialist, mental health care, programs like weight management, diabetes care, etc. And real accountability in terms of measurable patient care outcomes.

PCN, FCC, public health, whatever. But enough of the silos, turf wars and empire building for their own sake. Patients first.

As I said at the beginning, I'm no expert, so I'd welcome any corrections, clarifications or other interpretations.

May 17, 2012

As we know, health costs take a huge chunk of provincial budgets, and physician costs are a huge part of that. Ontario recently decided to roll back fees for certain procedures that because of improvements in technology etc. have become more lucrative for certain specialists. Some other provinces are thinking along the same lines.

Alberta doesn't have the best history when it comes to relations with doctors, and the docs didn't do themselves any favours when they further antagonized the government during the recent election, when they figured it wasn't too risky to do so.

In a cost-conscious environment, there aren't a hell of a lot of options available. People keep pushing the idea of nurse practitioners, which would be great in terms of improving access to care, but its a non-starter financially, since on top of regular salaries, they'd also need to be paid full benefits, holidays, overtime, overhead, education leaves, and all those other things that most doctors have to pay for themselves. Good luck with that.

People think doctors only want more money, but I think a lot of that is because of the low trust they have in the system, and how many times they've been screwed around because of it (Klein, AHS, etc.). I think there are other things they want, and they could be persuaded to take a modest cut in billings to pay for it.

What might docs be effectively willing to pay for? How about a better work environment.

Here's my proposal...

Pursue a real inquiry into physician intimidation. Government and health administration needs to stop treating physicians as enemies. And stop trying to confuse the public by inferring raw billings equates to salary.

Gut the ridiculous number of non-patient-care administrative staff in the AHS hierarchy, AHW, and the hospitals, and greatly increase accountability and transparency in terms of health outcomes there. The amount of frustration physicians have fighting with these organizations to care for their patients is epic.

Cut down on all the administrative and political fiefdoms, again by radically increasing accountability and transparency system-wide. Properly coordinate services and share knowledge rather than setting up multiple overlapping organizations that compete against each other for resources.

Frankly, reducing the frustrations that doctors have just trying to provide care for their patients in today's system should save most docs enough in alcohol and therapy bills to make up for any reductions in billings.

Once you get past a certain level of income to meet your basic needs, most people will be willing to pay to improve their quality of life. I'd say most doctors qualify.

So to recap, the gov't would save by lower physician billings and possibly lower admin overhead costs, offset by the costs of some really good people to truly bring in that level of accountability and transparency, and the associated costs inherent in any streamlining (not restructuring, we've had quite enough of that thank you). Docs would benefit by not having to put up with quite as much shit during their days.

Of course, there is a wee little problem.

For this to work, there would need to be a lot more trust on both sides, and real confidence that the system should, can and will be improved, with everyone fully committed to this.

May 08, 2012

The Mental Health Commission of Canada has released what they call the first mental health strategy for Canada. There's even some talk that something might be listened to by the federal government, though I don't see how that would happen. Even with the huge costs of mental health in the workplace that affects the bottom line of banks and oil companies. Stranger shit has happened.

Pauline is off in Philly at the American Psychiatric Association annual meeting. Lots of talk about the upcoming DSM-V of course, and apparently more than a few overly academic researchers who can't see the (in practice with real patients) forest for the (my narrow area of expertise data) trees. But apparently she's picked up a few scrunchy brains from the piles of schwag.

And I read Let's Pretend This Never Happened (A Mostly True Memoir) from Jenny Lawson (aka The Bloggess) who I'd never heard of before but I'm very glad I now know. Funniest shit I've read in a long time. And on her blog, she also has some of the most helpful and inspiring things to say to those affected by depression and other mental health issues. If you or someone you know is affected by mental health issues (and if you think you're not, you're in complete fucking denial) you owe it to yourself to listen to what she has to say.

Incidentally, she brings up the role of both therapy and meds. One nice thing is here in Canada psychiatrists (and other doctors) can bill for therapy, not just doing meds; in the USA, not as much, since most of the HMO's won't cover it. Therapy is a huge part of Pauline's practice, but this is still rare for psychiatrists even here. For most people, they'll need to pay a psychologist out of pocket. There are some community clinics etc. that are funded to provide psychological support, but not enough. For far too many people who could really benefit, the only option they can afford is whatever their doctor can provide, and all too often, it's just meds. Don't get me wrong, I'm a big believer that the right medication can make a world of difference, but it's often only part of the best solution. Better, affordable access in Canada to high-quality therapy for people with mental health issues would do a world of good.

There's still way too much stigma, misinformation, and way-to-hard-to-find good information out there. Lots of confusion, and I know talking with and hearing about many of Pauline's patients, too much frustration. It's fucking ridiculous that this is still the situation today on such a broad scale.

But it's also very hard to figure out how to help without just contributing to the noise.

Kudos to all the mental health practitioners out there making a difference one person at a time, and kudos to people like Jenny who can reach a larger audience and are making a difference that way.

September 11, 2011

April 04, 2010

By now many people in the Edmonton area have read the letter to the editor in St. Albert's local newspaper entitled Higher-earning families part of St. Albert's appeal, and the shit storm that developed on social media and beyond. I think enough has been said about the various logical fallacies (no or less drugs in rich schools? please...), and the sheer audacity of the value system the letter brings out.

The letter writers have also done an incredible disservice to the vast majority of people in St. Albert who have more respect for others, and done more to reinforce a negative stereotype about the community than would be countered by the hundreds and thousands of acts of daily good will that occur there.

It sounds like the letter writers more or less stand behind what they say, and I wouldn't be surprised if they believe the backlash is from a bunch of young socialists, live off government welfare type of people who don't properly contribute to society. The type who really are jealous of the position the letter writers have achieved in life, and will realize it if they grow up and find their way into the real world.

How did we get here?

Certainly a trend in society has been to increasingly measure people's value in terms of their economic power, how much they own, how much they consume. We see far too many articles, letters to the editor, etc. where people begin with "As a taxpayer...", and carry on by arguing the greater their share of the tax burden, the greater their voice should be, and the more their tax dollars should be about serving solely their priorities. People who pay less taxes (because they have less income) should have less of a say, and their priorities are trumped by those who contribute more.

We see this everywhere in civic and political discourse, and the Gazette letter carries forward that attitude to a horrid extreme.

People are part of communities, and societies. We recognize that diversity is a strength, not a weakness of those societies, and that contributions and value come in many different forms. When we forget that we are citizens and members of a community, and become only economic actors and taxpayers, we are not helping either ourselves or anyone else. We all lose.

And folks like the Perry's may not realize, but its not just the poor people you're scaring off. And I don't need to go all Richard Florida to reinforce that. Here's one small personal example.

Pauline and I are I would say pretty well off (she's a psychiatrist, I run a small business). We moved back to Alberta after ten years in Ontario. She took a job at the Sturgeon Hospital in St. Albert (amid several choices in the Edmonton area); and yes, people in St. Albert do need mental health care too. We also recently bought a house here, albeit in an older area, but worth as much or more as many in Kingswood or other new areas. Not having 2.2 children, the newer suburbs wouldn't be a great fit for our lifestyle, and I personally hate having to get in a car to go to a grocery store, bank, etc. We're walking distance to most things where we are now.

Even though we'd lived in Edmonton before, we didn't know too much about St. Albert, but had heard the snobby reputation. We've found it to be a nice city for essentially a bedroom community, with mostly friendly people, though yes, it could use a bit more vibrant of a downtown, a few more interesting restaurants, a bit more diversity, and a few more things to do.

When we first came out here we rented a place in Oliver in Edmonton, as our house in Ontario took a while to sell. When it did, we spent a long time discussing the pros and cons of where to buy a place, in Edmonton or St. Albert. Having just moved from a vibrant and diverse (economically, culturally, politically, etc.) small city out east, it wasn't an easy choice. Ultimately, doing a reverse commute from Edmonton to St. Albert every day (and with me working at home) just didn't make sense, and we bought in St. Albert.

I wonder though, if we'd read that letter to the editor in the Gazette around the time that we were selecting between jobs, or selecting where to live, if things might have been quite different.

October 16, 2009

WinWeb is one of those low-hype, high-value, long-term businesses that is really going out there and making a difference in the life of small business owners, helping them leverage the internet as a tool so that they can run their businesses more effectively. This is decidedly not one of these breathless "if you adopt our ground-breaking new business paradigm which we came up with in the shower this morning" ideas, but a collection of decidedly unsexy but essential tools and services offered at an affordable price. It stands in the background and helps reduce the friction of all those routine unpleasant things so small business owners can focus more on their business.

We should celebrate these types of businesses far more often than we do.

October 08, 2009

It's been a busy time the last month or so, both good and bad, but I guess that's partly to be expected in the transition time that we're in.

On the quite recent front, we finalized a house purchase yesterday (a week after it went on the market). It's a quite nice 20 year old two-story on a small cul-de-sac backing onto a ravine in a don't-have-to-drive-everywhere part of St. Albert. We get possession around end of November.

I guess I have to make some obligatory comment given its the first day of snow here, while back in Ontario it's still a bit more comfortable.

And because I still refuse to live in Alberta politically, I'll pick out only one incident on the intolerance and racism front which actually had a bright side to it. A transexual teacher was dumped by the Catholic school board in St. Albert (which is somehow the "public" school board) for the reasons one would imagine from such an open-minded organization. The bright side though is that there was actually a public outcry about this, heavily criticizing almost every aspect of the situation as far as the school board's actions, behaviour, responsibilities, ethics, funding, morals, role in the community, and more.

If you stand on your head, deprive yourself of oxygen, imbibe the substance that guy over there on the street corner is peddling, and squint just the right way, you'd think there might be a tiny glimmer of hope for this province yet.

August 28, 2009

I have to say that it has been wonderful to see how excited Jean-Claude has been with his hardware hacking in recent months. After being a bit more adrift in recent years, I'm glad he's found something he really enjoys to turn his considerable energy and inventiveness towards.

August 27, 2009

Dan Pink delivered an interesting talk at a recent TED conference. The focus was on how intrinsic (e.g. doing something that matters) and extrinsic (e.g. money) rewards can affect performance, particularly in creative work.

August 18, 2009

Going to be out in Guelph Sept 8-11 to get everything moved out (and into storage in Edmonton) until we find a place here.

Speaking of which, anyone in Guelph and area who wants to buy some furniture, exercise equipment etc. cheap please check out our stuff for sale.

With Pauline's job at the Sturgeon hospital in St Albert working out really well, and with me working from home, we're actually contemplating living out there rather than in Edmonton proper. Given that, hard to justify the daily commute really, both for time and environmental reasons (plus we'd probably be able to get rid of the second car).

While St Albert has its good points (a nice downtown, great farmer's market, a great park and trail system, rolling hills) it's urban sprawl personified. The newer cookie cutter suburbs (or heaven forbid the outlying 'acreage' communities) with the McMansions and where you have to drive everywhere don't really do it for us. Maybe we'll find some nice places in the older areas.

Thinking also about heading to Portland end of September for the annual Tcl/Tk get together; haven't made it to one of those in a while.